Transfer of a point mutation in

Mycobacterium tuberculosis inhA

resolves the target of isoniazid
Catherine Vilche`ze
1
, Feng Wang
2
, Masayoshi Arai
1
,
Manzour Hernando Hazbo n
3
, Roberto Colangeli
3
,
Laurent Kremer
4
, Torin R Weisbrod
1
, David Alland
3
,
James C Sacchettini
2
& William R Jacobs, Jr
1
Isoniazid is one of the most effective antituberculosis drugs,
yet its precise mechanism of action is still controversial. Using
specialized linkage transduction, a single point mutation allele
(S94A) within the putative target gene inhA was transferred
in Mycobacterium tuberculosis. The inhA(S94A) allele was
sufcient to confer clinically relevant levels of resistance to
isoniazid killing and inhibition of mycolic acid biosynthesis.
This resistance correlated with the decreased binding of the
INH-NAD inhibitor to InhA, as shown by enzymatic and X-ray
crystallographic analyses, and establishes InhA as the primary
target of isoniazid action in M. tuberculosis.
Isoniazid (INH), whose bactericidal activity against Mycobacterium
tuberculosis was discovered in 1952 (ref. 1), has become the foundation
of modern chemotherapy for active and latent tuberculosis because of
its excellent activity, low cost and relatively low toxicity. The mode of
action of INH has been controversial, with early reports suggesting
that INH affected cell permeability, inhibited DNA biosynthesis,
altered NAD metabolism or inhibited mycolic acid biosynthesis. The
mycolic acid biosynthesis inhibition hypothesis was validated by the
demonstration that INH-induced inhibition of mycolic acid biosynth-
esis correlated with cell death
2
, and the putative target of INH was
postulated in 1975 to be a desaturase, a cyclopropanase or an enzyme
involved in fatty-acid elongation
3
.
The development of plasmid genomic library transfer systems for
mycobacteria in 1994 (ref. 4) and the completion of the M. tuberculosis
genome sequence in 1998 (ref. 5) spurred further progress. By trans-
ferring M. tuberculosis genes on multicopy plasmids in M. smegmatis,
the inhA gene, encoding an NADH-specic enoyl-acyl carrier protein
(ACP) reductase, was identied in 1994 as a putative target for both
INH and the related drug ethionamide (ETH)
4
. The b-ketoacyl ACP
synthase (KasA)
6
and, more recently, the dihydrofolate reductase
(DHFR)
7
have also been proposed as targets of INH, based on INH
binding studies. Moreover, mutations in inhA and kasA have also been
found in M. tuberculosis INH-resistant clinical isolates
6,8
. The
determination of a clinically relevant drug target, however, requires the
ability to transfer such a single point mutation within a gene that
putatively encodes a drug target and demonstrate that this transfer is
sufcient, by itself, to confer drug resistance.
We performed a specialized linkage transduction
9
to introduce the
inhA(S94A) point mutation, previously associated with INH resis-
tance
4
, linked to a gene conferring hygromycin resistance, into
M. tuberculosis (Fig. 1a) or M. bovis BCG (Supplementary Methods
online). Two different types of hygromycin-resistant recombinants
could be obtained, depending on the site of recombination with respect
to the S94A mutation, resulting in INH resistance or susceptibility
(Fig. 1b). In M. tuberculosis, 51% of the hygromycin-resistant trans-
ductants were INH resistant (Fig. 1c). We screened the transductants
for the absence or presence of the inhA(S94A) allele using sequence
analysis or a hairpin-shaped primer assay and found a 100% correla-
tion with INH resistance, ETH resistance and the presence of the
inhA(S94A) allele. As predicted, the introduction of the S94A mutation
was sufcient for conferring at least a vefold resistance to INH and
ETH in M. tuberculosis and M. bovis BCG (Supplementary Table 1 and
Supplementary Fig. 1 online). We also introduced three kasA muta-
tions (G269S, G312S and F413L), found in INH-resistant M. tubercu-
losis clinical isolates
6
, into M. tuberculosis or M. bovis BCG using
specialized linkage transduction to test whether these mutations con-
ferred INH resistance. The presence of mutated kasA alleles was
conrmed by sequencing. None of the transductants obtained showed
any detectable level of resistance to INH (Supplementary Table 1
online). These results indicate that no single kasA mutation was
sufcient, by itself, to confer INH resistance in M. tuberculosis.
The bactericidal activity of INH correlates with the inhibition of
mycolic acid biosynthesis
2
. Therefore, we analyzed two inhA isogenic
strains carrying either the wild-type inhA allele (mc
2
4910) or the
inhA(S94A) allele (mc
2
4911) for their resistance to mycolic acid
biosynthesis inhibition in the presence of increasing concentrations
of INH. At 0.25 mg/ml INH, mycolic acid biosynthesis was fully
inhibited in INH-resistant mc
2
4910, but not in INH-resistant mc
2
4911
(Fig. 1d). Complete inhibition of mycolic acid biosynthesis in both
M. tuberculosis isogenic strains occurred at twofold the minimum
inhibitory concentration (MIC), in agreement with the bacteriocidal
MIC activity.
As INH resistance can be mediated by overexpression of inhA
10
, we
compared the inhA mRNA levels between mc
2
4910 and mc
2
4911 at
different concentrations of INH, using a molecular beacon RT-PCR
assay. The mRNA levels were similar in both strains even at high
concentrations of INH (Fig. 1e), and this corresponded to InhA
protein levels (Fig. 1f). Therefore, INH resistance in mc
2
4911 was not
caused by inhA overexpression. In contrast, mc
2
4914, an INH-resistant
Received 16 March; accepted 11 July; published online 13 August 2006; doi:10.1038/nm1466
1
Howard Hughes Medical Institute, Department of Microbiology and Immunology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York
10461, USA.
2
Department of Biochemistry and Biophysics, Texas A&M University, College Station, Texas 77843, USA.
3
Division of Infectious Disease, Department of
Medicine and the Ruy V. Lourenc o Center for the Study of Emerging and Re-emerging Pathogens, New Jersey Medical School, University of Medicine and Dentistry of
New Jersey, 185 South Orange Avenue, MSB A920B, Newark, New Jersey 07103, USA.
4
Laboratoire de Dynamique Mole culaire des Interactions Membranaires, CNRS
UMR 5539, Universite de Montpellier II, case 107, Place Euge` ne Bataillon, 34095 Montpellier Cedex 05, France. Correspondence should be addressed to W.R.J.
(jacobsw@hhmi.org).
NATURE MEDICINE VOLUME 12 [ NUMBER 9 [ SEPTEMBER 2006 1027
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M. tuberculosis spontaneous mutant carrying the inhA expression
region mutation (C15T), which had been proposed as inducing
overexpression of inhA, showed a 20-fold increase in inhA mRNA
levels (Fig. 1e) and subsequent InhA protein levels (Fig. 1f). It
has been suggested that this mutation maps to the ribosomal initia-
tion site, so it was unclear whether it affected transcription or
translation. This analysis shows that the C15T inhA promoter
mutation mediates enhanced transcription of inhA mRNA levels,
resulting in INH resistance.
It was previously shown that kasA is induced in mycobacteria
treated with INH
6
. In agreement, we found that M. tuberculosis strains
H37Rv and mc
2
4910 have increased kasA mRNA levels when treated
with INH (Fig. 1e). In contrast, mc
2
4911 and mc
2
4914, which are
resistant to INH, showed no increase in kasA mRNA levels when
treated with INH at or below the MIC. An increase in the level of kasA
mRNA was observed in mc
2
4911 at 1.0 mg/ml INH. This suggests that
kasA mRNA levels were induced only when InhA was inhibited, and
that the increase in kasA expression does not correlate with INH
resistance, a fact that is consistent with the observation that kasA
overexpression in fast- and slow-growing mycobacteria does not
increase resistance to INH
10
.
It has been shown that InhA is inhibited by a covalent INH-NAD
adduct
11
, the product of activated INH with NAD
+
(ref. 12). To
determine whether the InhA(S94A) enzyme is resistant to inhibition
by the INH-NAD adduct, we measured the inactivation of wild-type
and mutated InhA by this adduct in a dose-dependent fashion. The
InhA(S94A) enzyme was 17 times more resistant to inhibition by
the INH-NAD adduct (IC
50
, 323 41 nM for the InhA(S94A)
enzyme versus 19 10 nM for the wild-type enzyme), and showed a
30-fold increase in the K
i
value for the INH-NAD adduct (K
i
for the
S94A mutant protein is 172 22 nM; K
i
for the wild-type protein is 5
3 nM). To determine the molecular basis for the reduced inhibition of
the INH-NAD adduct to the InhA(S94A) enzyme, we co-crystallized
the InhA(S94A) protein with the INH-NAD adduct (Fig. 2a)
and compared it to the wild-type protein structure. Although the
position and orientation of the INH-NAD adduct was nearly identical
in the active sites of the wild-type (Fig. 2b) and InhA(S94A)
(Fig. 2c) proteins, the loss of the serine residue resulted in
the movement of an ordered water molecule that disrupted the
hydrogen bonding network, which probably decreases the binding of
the adduct to the InhA(S94A) protein.
Elucidating the mechanism of action of INH has been a complex
endeavor because of : (i) the prior inability to transfer point mutations
in M. tuberculosis; (ii) the clinically irrelevant binding of INH to
proteins
6,7
; (iii) the fact that INH is a prodrug that requires modica-
tion before becoming active
13
; (iv) the 100-fold difference in suscept-
ibility between M. smegmatis and M. tuberculosis; and (v) the initial
inability to explain the accumulation of saturated C
26
fatty acid upon
INH treatment
14
. Although a drug may bind to a number of different
enzymes in vitro, the validation of a proposed target requires in vivo
data. In vivo binding can be established by identifying amino acid
substitutions within the target enzyme that reduce binding or by
Rv1482c PmabA
PmabA
inhA hemZ Rv1486c
1 2 1/2
mabA inhA(S94A) hyg hemZ
M. tb chromosome
phAE2067
Allelic exchange - Type 1
Allelic exchange - Type 2
Rv1482c
PmabA Rv1482c
inhA(S94A)
inhA(wt)
hyg
hyg
hemZ
hemZ
+
+
+ +
Hyg
R
INH
R
ETH
R
Hyg
50
INH
0.2

methoxy
keto
INH (g/ml): 0 0.06 0.12 0.25 0.5 1.0 0 0.06 0.12 0.25 0.5 1.0
FAMEs
MAMEs
mc
2
4911 mc
2
4910
INH (g/ml) 0 0.2 1.0
8
6
4
2
0
125
100
75
50
25
0
inhA/sigA kasA/sigA
*
*
*
*
*
*
H37Rv mc
2
4911 mc
2
4910 mc
2
4914 H37Rv mc
2
4911 mc
2
4910 mc
2
4914
InhA
(g/ml)
MW
37
29
INH 0
H37Rv
0.2 1.0 0 0.2 1.0 0 0.2 1.0 0 0.2 1.0
mc
2
4911 mc
2
4910 mc
2
4914
a
b
c
d
e
f
Figure 1 Construction and analysis of M. tuberculosis inhA(S94A) (Supplementary Methods). (a) Schematic representation of the specialized transducing
phage. A replicating shuttle phasmid phAE2067 containing mabA, inhA carrying the S94A mutation, a hyg resistance cassette and hemZ was used to
transduce M. tuberculosis (M. tb). The two possible sites of recombination are marked 1 and 2. (b) The recombination can occur either before the point
mutation (crossover type 1), resulting in an INH-resistant and ETH-resistant recombinant carrying the S94A mutation, or after the point mutation (crossover
type 2; the strain contains a wild-type inhA gene). (c) Individual M. tuberculosis H37Rv inhA(S94A) transductants (n 150) were screened by picking and
patching onto plates containing either hygromycin (50 mg/ml) or INH (0.2 mg/ml). (d) Fatty acid methyl esters (FAMEs) and mycolic acid methyl esters
(MAMEs) proles of mc
2
4910 (INH-sensitive) and mc
2
4911 (INH-resistant). The M. tuberculosis strains were treated with different concentrations of INH
for 4 h and labeled with [1-
14
C]-acetate.
14
C-labeled FAMEs and MAMEs were separated by thin-layer chromatography and detected by autoradiography.
(e) Analysis of inhA and kasA mRNA levels of M. tuberculosis strains by RT-PCR. The M. tuberculosis cultures were treated with INH for 4 h before measuring
the inhA and kasA mRNA levels. inhA and kasA values were normalized using sigA levels. Means (n 3) s.e.m. (*P o 0.05). (f) Western blot analysis of
InhA protein levels of M. tuberculosis strains treated with INH for 4 h. InhA was detected in total protein extract using rabbit antibodies to InhA raised against
the M. tuberculosis InhA protein.
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showing target overexpression, both of which confer clinically relevant
drug resistance.
The coupling of specialized linkage transduction with enzymatic
analyses and X-ray crystallography has enabled us to establish the pre-
cise molecular mechanism by which INH inhibits InhA, and supports
the premise that inhA encodes the primary target of INH. Further-
more, the observations that inhA modication or overexpression
10
, or
altered NADH/NAD ratios
15
, confers co-resistance to ETH support
the hypothesis that InhA is a common target of both INH and ETH.
In addition to identifying the actual drug target of INH, the INH
story has unveiled a new paradigm of drug action, in which
INH functions by covalently modifying an enzyme cofactor. This
paradigm provides important insights that may be valuable in devel-
oping new drugs against multidrug resistant and extensively drug-
resistant M. tuberculosis (http://www.cdc.gov) as well as against other
pathogenic mycobacteria like M. ulcerans and M. leprae.
Note: Supplementary information is available on the Nature Medicine website.
ACKNOWLEDGMENTS
We gratefully acknowledge G. Morlock for sending us the DNA from the
INH-resistant clinical isolate carrying the inhA(S94A) mutation. L. Kremer is
supported by a grant from the Centre National de la Recherche Scientique
(ATIP Microbiologie Fondamentale). J.C.S. acknowledges the Robert A. Welch
Foundation grant A-0015. We also acknowledge support for this work from
US National Institutes of Health grants AI43268 and AI46669, and from the
Structural Genomics Project grant 1P50GM6241. We also thank G. Hatfull
for careful reading of this manuscript.
AUTHOR CONTRIBUTIONS
C.V. performed specialized transductions of inhA in M. tuberculosis and BCG
and analyzed the transductants for their inserts, INH and ETH resistance and
biochemical resistance to INH, and wrote most of the manuscript with W.R.J.
F.W. prepared the INH-NAD adduct, performed the InhA enzymological analyses
and X-ray crystallography. M.A. constructed the phages for transduction and
performed and analyzed the kasA allelic exchanges in M. tuberculosis and
M. bovis BCG. T.R.W. sequenced the transductants. M.H.H. and R.C. conducted
the hairpin-shaped primer assays and mRNA experiments. L.K. provided
the pMV261::kasA constructs and did the western blot analysis. D.A., J.C.S.
and W.R.J. contributed to the design of the study, data analysis and
data interpretation.
COMPETING INTERESTS STATEMENT
The authors declare that they have no competing nancial interests.
Published online at http://www.nature.com/naturemedicine/
Reprints and permissions information is available online at http://npg.nature.com/
reprintsandpermissions/
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a b c
Gly14
Gly14
WAT5
Ser94
Ile21
O3
O9
ZID
Ala94 Ile21
WAT9
O3
O9
ZID
2.92
3.21
2.72
2.90
2.69
3.26
2.78 2.82
2.91
2.85
Ala94
INH-NAD
Figure 2 X-ray crystallographic analysis of the INH-NAD adduct bound to wild-type InhA or InhA(S94A) protein. (a) Crystal structure of the S94A mutant
protein with the INH-NAD adduct. (b) In the InhAINH-NAD structure, the oxygen O9 of the phosphate of the INH-NAD adduct forms one hydrogen bond
with the main-chain nitrogen atom of Ile21 and one hydrogen bond with a well-ordered water molecule. This water molecule is part of a hydrogen-bonding
network formed by interactions between the side-chain oxygen atom of Ser94 (2.85 A

), the main-chain oxygen of Gly14 (2.78 A

) and the oxygen atoms O3

(3.26 A

) and O9 (2.82 A

) of the INH-NAD adduct. The same water molecule is within hydrogen-bonding distance of the main-chain nitrogen atoms of Ala22
(2.9 A

) and Ile21 (3.3 A

). (c) In the InhA(S94A)INH-NAD structure, this hydrogen-bonding network is disrupted by the loss of the hydroxyl group in the
S94A substitution. Although the water molecule is still visible in the same position, it is 2.92 A

from the main-chain oxygen of Gly14 and out of range of

hydrogen bonding interaction with the oxygen atom O3 (3.54 A

). The water molecule is 0.2 A

and 0.1 A

closer to the adjacent residues Ala22 and Ile21,

which form hydrogen bonds with their main-chain nitrogen atoms, respectively.
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